1. Acute Otitis Media & Acute Otitis Externa
Grand Rounds
Presented by: Cathleen McKnight, DNP, APRN, NP-C
September 24, 2015

2. Objectives Learning objectives for respective condition
Identify incidence & risk factors
Explore causation
Review anatomy and pathophysiology
Recognize signs & symptoms
Distinguish appropriate diagnostic criteria & testing
Survey differential diagnoses
Evaluate best practice treatment modalities
Discover applicable ICD-10 coding

3. Acute Otitis Media (AOM)

4. AOM: Introduction Middle ear infection
>80% of children have ≥1 episode by age 2
Most common cause for abx administration
80-90% cases occur in <6 years of age

5. Epidemiology Family hx Day care Race > Fall/ winter Tobacco smoke
Lack of breastfeeding
Supine feeding
Pacifier use
Developing areas
↓ Socioeconomic status
Anatomic anomalies
Immunologic deficiencies
Family hx
Day care
Race
> Fall/ winter
Tobacco smoke
Air pollution
Boys> Girls

6. Etiology Most viral & self-limiting Bacterial AOM S. pneumoniae (40%)
H. influenzae (25-30%)
M. catarrhalis (10-15%)

7. Pathophysiology Eustachian tube in infants is shorter, > angle
Eustachian tube obstruction leads to negative pressure within the middle ear and movement of capillary fluid into the space (OME)
Transudation of inflammatory mediators into the middle ear may cause mucosal edema/ infection (AOM)
Normal TM

8. History & Exam History Preceding coryza Otalgia Irritability
Sleep disturbance
Fever
Decreased appetite
N & V
Diarrhea
Exam
Acute infection
Middle ear inflammation
& effusion
with perforation

9. Diagnostic Testing Clinical diagnosis* Pneumatic otoscopy Tympanometry
Acoustic reflectometry
Audiometry
Bacterial culture

10. Pneumatic Otoscopy
95% sensitive, 80% specific (with accurate execution)
Assess mobility of TM
Seal is key!
Causes of immobility
Fluid in middle ear
Perforation
Poor seal
Video of Pneumatic Otoscopy

11. Differential Dx Otitis media with effusion Myringitis Mastoiditis
Cholesteatoma
Myringitis
Cholesteatoma

12. Prevention Primary prevention Secondary prevention
Pneumococcal immunization
Influenza immunization
Probiotics
Secondary prevention
Decreasing modifiable risk factors
No support for prophylactic abx
Pain control
Antibiotics

13. Pain Control Simple analgesics Topical agents Narcotics Distraction
NSAIDs
Tylenol
Topical agents
Antipyrine/benzocaine otic
Limited benefit
Short duration
Narcotics
Distraction

14. Antibiotics To prescribe or not to prescribe? Delayed abx therapy
Limited effect
Shorten recovery by 1 day
Delayed abx therapy
A place to SNAP?
Optimal abx
Amoxicillin-based therapy
Cefdinir
Azithromycin, Ceftriaxone

15. Follow-up Routine follow-up discouraged
Improvement in 2-3 days
Most asymptomatic at 1 week regardless of tx
Recurrent/ resistant infections
Broader spectrum abx
Tympanostomy tubes
Long-term complications rare

16. ICD-10
Diseases of the middle ear
H65-H75

17. ICD-10 Documentation Type Infectious agent Temporal factors Laterality
Tympanic membrane rupture
Secondary causes

18. ICD-10 Miscellaneous essential codes W61.42 Struck by Turkey
Y93.D1 Accident while knitting or crocheting
W56.22 Struck by orca, initial encounter
V91.07 Burn due to water-skis on fire
V97.33XD: Sucked into jet engine, subsequent encounter
Z63.1: Problems in relationship with in-laws

19. Acute Otitis Externa (AOE)

20. AOE: Introduction
Superficial skin infection of the external auditory canal
Bacteria most common cause*

21. Epidemiology 10% of people develop AOE in lifetime
Highest risk in childhood
Females > Males
Summer
Warmer temps
High-humidity
After swimming
Occlusive devices

22. Etiology Mostly bacterial Often polymicrobial & multifactorial
P. aeruginosa (20-60%)
S. aureus (10-70%)
Often polymicrobial
& multifactorial
Fungal infections 2-10%
Idiopathic
Trauma
Chemical irritants
Allergy
Dermatologic conditions

23. Pathophysiology Obstruction Absence of cerumen Trauma
Alteration of the pH of the ear canal

24. History & Exam History Exam Acute onset otalgia Pruritis Fullness
Decreased hearing
Tender tragus/pinna
Exam
Canal inflammation
& erythema
Drainage & debris
Regional lymphadenopathy

25. Diagnostic Testing Clinical diagnosis* Bacterial culture
Pneumatic otoscopy
Tympanometry
Microscopy
CT scan
MRI

26. Differential Dx AOM Otomycosis Psoriasis Furunculosis
Contact dermatitis
Viral infections
Carcinoma of ear canal
Cholesteatoma
Malignant OE
Cholesteatoma

27. Prevention Primary prevention Secondary prevention Avoid risk factors
Preserve skin integrity
Secondary prevention
Decreasing modifiable risk factors
Treat skin disorders
Pain control & antibiotics
Occlusive ear plugs for swimming
Use acetic acid-containing ear drops after swimming

28. Treatment Pain control Clean canal Treat inflammation & infection
Topical therapy
Antiseptics
Abx
Glucocorticoids
Acidifying solutions
Video of Ear Wick Placement

29. Topical Therapy Ciprofloxacin/ dexamethasone (Ciprodex 0.3%/0.1%)
4gtt BID x7-10 days
Acetic acid 2%
-OR-
Acetic acid/ hydrocortisone 2%/1%
Ofloxacin 0.3%
5-10 gtt QD x7 days
Oral abx therapy should be utilized if resistance to initial treatment, or high risk patient (ex. diabetic)
Ciprofloxacin mg BID
-AND-
Topical therapy
5 gtt for kids/ 10gtt for adults
Cortisporn otic – 3 for kids for 3-4day/ 4gtt for adults 3x daily
Neomycin/ polymixin D/ hydrocortisone
(Cortisporin otic)
3-4gtt TID-QID x7-10 days

30. Follow-up 60-90% resolution ≤ 10 days irrespective to agent choice
Routine follow up not required

31. ICD-10 Otitis externa H60 H60.11 Cellulitis of right external ear
H Diffuse otitis externa, left ear
H Swimmer’s ear, right ear
H Acute eczematoid otitis externa, bilateral

32. R46.1 – Bizarre personal appearance
ICD-10
R46.1 – Bizarre personal appearance

33. Questions/ Comments?

34. References

35. References